Diseases of larynx

1. Diseases of larynx Dr. Manal Bukhari King Saud University Otolaryngology Assistant professor consultant Phonosurgeon King Abdulaziz University

2. Larynx

3. Skeletomembranous framework of larynx Thyroid cartilage Cricoid cartilage paired arytenoids cartilage Epiglottis Hyoid bone

4. Thyroid cartilage : Shield like Cricoid cartilage : Signet ring shaped. the only complete skeletal ring for the air way. ?Both thyroid and cricoid cartilage ? hyaline ? calcification Cricothyroid joint Synovial joint ? hinge motion

5. Arytenoid cartilage : Pyramidal shaped Apex ,vocal & muscular process. Cricoarytenoid joint Synovial rocking motion Corniculate and cuneiform cartilage:

6. Epiglottic cartilage : Leaf like structure Elastic cartilage Thyroepiglottic ligament Hyoepiglottic ligament glossoepiglottic fold ? valleculae

7. Laryngeal membranes : Quadrangular membrane. Upper and lower border ?thickened aryepiglottic fold Vestibular fold Triangular membrane (conus elasticus). Medial and lateral border is free? thickened ?vocal ligament

8. Laryngeal mucosa : All mucosa from trachea to aryepiglottic fold ?ciliated columnar epithelium. ¤ except vocal cord and aryepiglottic fold ?squamous epithelium

9. Laryngeal musculature: Extrinsic depressors. (C1-C3) Sternohyoid sternothyroid thyrohyoid, omhyoid. Extrensic elevators. Genohyoid (C1), diagastric (CNV-CNVII) mylohyoid (v) stylohyoid (VII)

11. Intrinsic musculature Abductors : posterior cricoarytenoid (PCA) Adductors: thyroarytenoid (TA) ,lateral cricoarytenoid (LCA) ,cricothyroid, interarytenoid

12. Histopathology

13. Vocal cord layers Histology: Squamous epithelium Lamina propria superficial layer Reink’s space Intermediate layer. Deep layer. Intermediate + deep layers =vocal ligament Vocalis (thyroarytenoid muscle)

14. Blood supply : Superior and inferior laryngeal artery and veins. lymphatic drainage: above vocal cord ? up deep cervical lymph node. Below vocal cord lower ?deep cervical node

15. Nerve supply: Superior laryngeal nerve Internal branch (sensory) +superior laryngeal artery . External branch ?cricothyroid muscle Recurrent laryngeal nerve RT side: crosses the subclavian artery LT side: arises on the arch of the aorta deep to ligamentum arteriosum it is divided behind the cricothyroid joint Motor ?all the intrinsic muscles except ? Sensory

16. Pediatric airway anatomy The neonates are obligate nasal breathers until 2 months . The epiglottis at birth is omega ? shaped the infants have high larynx C1-C4

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19. Applied physiology of the larynx Protection of the lower air passages Closure of the laryngeal inlet Closure of the glottis Cessation of respiration Cough reflex (forced expiration is made against a closed larynx

20. Phonation : Voice is produced by vibration of the vocal cord Source of energy is the airflow Normal vocal fold vibration occurs vertically from inferior to superior The mouth ,pharynx ,nose ,chest (resonating chambers) Respiration

22. Voice mechanism Speaking involve a voice mechanism that is composed of three subsystems. Air pressure system Vibratory system Resonating system The “spoken word” result from three components of voice production : Voiced sound, resonance, and articulation

23. Voiced sound :the basic sound produced by vocal fold vibration “buzzy sound” Resonance: voiced sound is amplified and modified by the vocal tract resonators ( throat, mouth cavity ,and nasal passages ) Articulation: the vocal tract articulators (the tongue ,soft palate, and lip) modify the voiced sound

24. Vocal fold vibrate rapidly in sequence of vibratory cycles with a speed of about: 110 cycles per second (men)= lower pitch 180 to 220 cycles per second (women)=medium pitch 300 cycles per second (children)= higher pitch Louder voice : increase in amplitude of vocal fold vibration

25. Vocal cord vibration Bernoulli effect

26. Laryngeal sphincters True vocal cord false vocal cord Aryepiglottic sphincter

27. Evaluation of the dysphonic patient HISTORY Dysphonia (hoarseness) URTI,fever ,cough ,(voice ,tobacco or alcohol abuse ), dysphagia ,aspiration , breathing difficulty ,wt lost ,GERD ,trauma , previous surgery . EXAMINATION Indirect laryngoscope (mirror) Direct laryngoscope Fibreoptic flexible scope Stroboscopy Acoustic analysis

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34. Disease of the larynx Congenital abnormalities of the larynx : Laryngomalacia most common cause of stridor in neonate and infants Laryngeal finding : Inward collapse of aryepiglottic fold (short) into laryngeal inlet during inspiration . Epiglottis collapses into laryngeal inlet. SSX: intermittent inspiratory stridor that improve in prone position . DX: HX and endoscopy RX: observation Epiglottoplasty Tracheostomy

36. Subglottic stenosis : Incomplete recanalization,small cricoid ring types: membranouse Cartilaginous mixed Grades: I <70% II 70-90% III 91-99% IV complete obstruction SSX :biphasic stridor ,failure to thrive . DX: chest and neck X-ray ,flexible endoscope RX: tracheotomy grade I - II ; endoscope (CO2 or excision with dilation ) Grade III –IV: open procedures: Ant cricoid split LTR OR CTR

38. Laryngeal web: incomplete decanalization Types: Supraglottic Glottis Subglottic SSX: weak cry at birth ,variable degrees of respiratory obstruction DX: flexible endoscope Rx : no treatment laser excision open procedure+ tracheostomy

40. Subglottic haemangioma Most common in subglottic space 50% of subglottic hemangiomas associated with cutaneous involvement Types: capillary (typically resolve) Cavernous SSX: biphasic stridor DX :endoscope RX: observation Crticosteroid CO2 LASER

42. Traumatic conditions of the larynx Direct injuries (blows) Penetration (open) Burns (inhalation , corrosive fluids) Inhalation foreign bodies Intubations injuries : Prolonged intubation Blind intubation too large tube pathology : Abrasion ? granulomatous formation ….subglottic stenosis SSX; hoarsness , dyspnoea RX: voice rest endoscopic removal prevention

47. Vocal fold lesions secondary to vocal abuse and trauma Vocal nodules (singer’s nodules) At junction of ant 1/3 and mid 1/3 RX : voice therapy surgical excision

48. Vocal fold polyp : Middle and ant 1/3 , free edge , unilateral Mucoid , hemorrhagic RX : surgical excision

49. Vocal fold cyst ; congenital dermoid cyst mucus retention cyst RX: surgical excision

50. Reinke’s edema RX: voice rest ,stop smoking surgical excision

51. Laryngocele Air filled dilation of the appendix of the ventricle ,communicates with laryngeal lumen congenital or acquired types : External : through thyrohyoid membrane Internal : Combined Rx :marsupialization

53. Vocal cord paralysis Causes: Adult Neoplastic Iatrogenic : Idiopathic Trauma Neurological infectious systemic diseases Toxins children Arnold chiari malformation Birth trauma

54. SSX: Dysphonia Chocking Stridor

55. Vocal cord position : Median ,paramedian ,cadaveric Rx : Self limiting or permanent paralysis For medialization : Vocal cord injections Gelfoam, fat, collagen, Teflon. Thyroplasty For lateralization: cordotomy Thyroplasty tracheotomy

60. Inflammation of the larynx Acute viral laryngitis: Rhinovirus, parainfluenza SSX: dysphonia , fever cough Rx: conservative Acute epiglottis : Haemophilis influnzae B 2-6 years Ssx: fever , dysphagia ,drooling ,dyspnea, sniffing position , no cough, normal voice. DX : x-ray (thumbprint sign) Rx: do not examine the child in ER Intubation in OR IV abx corticosteroid

62. Croup (laryngotracheobronchitis ) Primary involves the subglottic Parainfluenza 1-3 1-5 years SSX: biphasic stridor, fever , brasssy cough , hoarseness , no dysphagia DX: x-ray ,steeple sign RX: humidified oxygen,racmic epinephrine ,steroid

64. Diphtheritic laryngitis Causes: Corynebacterium diphtheriae Ssx: Cough ,stridor ,dysphonia , fever Greyish –white membrane Treatment: Antitoxin injection Systemic pencillin Oxygen tracheostomy

65. Fungal laryngitis : Immunocompromised candidiasis ,aspergillosis Ssx: dysphonia ,cough odynophagia RX: antifungal regimen

66. Recurrent respiratory papillomatosis: 2/3 before age 15 rarely malignant change HPV 6-11 Risks: younger first time mother (condyloma acuminata) Lesions: wart like (cluster of grapes ) Types : juvenile Senile SSX: Hoarseness stridor RX; laser excision ,microdebrider Adjunctive therapy: acyclovir , interferon …

70. Malignant neoplasms of the larynx 1-5 % of all malignancies All are squamous cell carcinomas ; Ssx: Hoarseness ,aspiration, dysphagia , stridor , wight lost risks: Smoking ,alcohol ,radiation exposure . Classification : Supraglottic : 30-40-% of laryngeal Ca 25-75% nodal metastasis Glottic: 50-75% Limtted regional metastasis Subglottic : Rare 20% regional metastasis RX : Radiotherapy hemilaryngectomy . Total laryngectomy + neck dissection